20532APPLICANT TO FILL IWINFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
building Project Idcntl
scionten! /
Y
PERMIT N20532
Building Address:
13
are: one:
nef ,q t
CITY OF CUPERTIN04BUILDING DIVISION
APPLICATION I PERMIT
-&ntmctoe.Name: Lic.N°:
Q �3
BUILDINGELFGTMCAI.MUMBING-MECHANICAL
CATEGORY
CONTROL M
Architect/Engineer. I Lie N.
Adareac -
Q'fY +`ELECTRIC PERMtF'FEE y
UILDINGPERMIT_INFO'�{.-^r
- _. .
1 PERMITISSUANCE Q
❑.„.... ❑
❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby oaffirm that lambce3.fthunder iros.ldPo fC1.1... 9(comm.c
If...h i.f.n7lX10)ofDivlalon3aflheBuelnesandPcofnsiemCode,and r^Y
license le In full fo and d(ect.
License ClassS�Lictl
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
Date Contractor
UPT0200 ANTS
! /
301-1000AMPS
ARCHITECTS DECLARATION
I understand my plzm shall be used as public records.
OVERIOg0AMPS
- SQ. FI. FLOOR AREA
$/SQ.FL
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby a(firmthat I am exempt from the Contractor's License Law for the
16 SPECIAL CIRCUIT/MISC - (U .
TEMP. METER OR POLE INST.
POWER DEVICES
following reason.!Section 70715, Business and Pm(eulons Code: Any city or
countywhkh requires a Permit to mmtme5 alter, improve, dennlbh, or repair
anystm=mprlortolb Wuance,aborequireatheappUmntforsuchper tto
f 1, a signed statement that he V licensed pursuant to the providom of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
sion3 of the Business and Profession Code) orthat he b exempt therefromand
the basis for the alleged exemption. Any vloldin. o(Sectl&n 70715 by any
applicant (ora permit subjeafsthe applicant to a civil penalty of not more than
five hundred dollars ($50%.
❑ I, as owner of the property, or my employe. with wages as thoracic
SWIMMING POOL ELECTRIC
'sal
POIOUTLETSSWITCHFSFIXTVRFS t,Y
VALUATION
NEW RESIDENTIAL E.ECTR SQgT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work and thestmcome b not intended or offered for
sale
sale bee 7040 Business and Pedfeyiom Code The Contractors License Law
2—
does not apply to an owner of property who Wilds or improvens thereon, and'L
don such work h(msefforthrough hisown employees, provided that such
SC OlT�"�A�d Ir cid+�
OCC. CROUP
RFS. UNITS
improvements are not Intended oraHeted (orsale. If, howsvepthebuRding or
improvement isaold wlthlnone)Barofcompldt Ntheowner-bullderwOI have
t)LIIurdenof proving that he dial not build or improve for purpose°(oris.).
LJ L as emar of the property, am exclusively mntractung with licensed
conmcmrs to mmtmrd the project (Sec. 7044, Business and Professions Code:
TOTAL:
;,,V
Q7y: ., 'Y PLDM 4C'i`PERMITy'", �S�Y FEE.aty
PERMIT ISSUAN
FLOOD TONE
APN
The Cosdractors Lt.. Law does not apply to an owner of property who
builds or improves thereon, and who contra. for inch ptajeata with a
coli actortU licensed pursuant m the Contract&. License Law.
LII am exempt under Sec B k P C for this reason
ALM -DRAIN h .� (EA)
BACKFLOW PROTECT.DQUTSIDEFEES
'hT „+a _r FEE`SU11'f111ARY„ ;y {az*$,ata"
--
Owner Date
DRAINS. FLOOR, ,A ND.
Y_ N_
RECEIPT tl
LAX Y N_RECEIPT
WORK MAN COMPENSATION DECLARATION
[31 hereby affirm that I have a certificate °( to
FD(TURES� PEI
consent sect -Insure, or a
38eofWorkers'Compemuationlnsurance ore certified
N
S
GAEA. SYSTEM -1 IN ETS
mpythereof(Sec.
3$000,
0,LaLab C.7
y N
Polley tl
RECFIlPI tl
BUILDING DIVISIONFEES
GAS EA. SYSI1M-0VFR /
Com any
zertified copy Is hereby furnished.
Certified copy b (Bed with the city Inspection division.
GREAS DUS[RL A
LA ECIC FEE
GREASE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissecti°n need not be completed I permit pedt isfor oro hundred dollars
WOO
I certify that in the performance of the work for which this permit is issued,
I shag not employ any person In any manner so as to become subject to the
Workers Compensation Lim of California. Date
AID
Date
Date Recei t#
Sb.WFA SANIT RM EA 2(10
WATERlIEATER / /m FfTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREAIT
Applicant
NOTICEco esubjeAM:e, after,.longthis .tion pro of Exemption, ofthe Labor
should become forto thwith
Code, you must (arthwith comply with such provisions orchis permit shall be
co Worken'Comprovisinpmvuio permit Labbe
doomed revvk i;
Date Recei t#
NEW RESIDENTIAL- PLMR. SQFT.
TOTAL:
BUIL ING FE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there b a construction lend ing agency for the perform-
ance of the work for which this permit u leaved (Sec. 3097, Civ. C.)
Linder'. Nature
Lender's Address
I certify that I have read this application and statethat theabove information
iscomect.I.greto comply with all city and county ordinances and state laws
TOTAL:
�.. -.*. ,.. Fr,
QTY. i.: ,:';MECHANICALL'PERMIT-";:'�'%%?;FEE'P�'
ELECTRIC FEE
aJ
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building mvtruction, and hereby authorize representatives of this
city to enter upon the above-mentioned property f. Inspection purposes.
(We) agree to save, hademnify an d keep harmless the City of Cu pent Ino
agaWt liabilities, dgments, coetsand expense whit In anywayacmre
agar id City once of eti d T.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(1010,000 CFM)
Date Receipt#
SUBTOTAL'
03,
AIRHANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
igmmreof Applicant/ �pe
rontracror Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCL SURE
HEATING UNIT (TO 100,MD BTU)
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
He❑alt .rand Safety Code, Section 75532(.)?
Dale Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL'Yea
VENTILATION FAN (SINGLE RESID)
ISSUANS.EDATE
L'
�) 7 "1990
Willtheapplicantorfutombuildingoccvpantuseequipmentordevices
which emit hazardous.o contaminants as defined by the Bay Area Air
Quality Management District?
4 Yea v e° materialsrequ 25505,sundernd2S53r6.93of
haveread Health I
the Cai7f&mle Health ASafety Code, Sectiorr5505,ve.
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Ff.
does not tenant, that
usponsi ntl that if the that 7e is
ingoccupant
the threntlye
mnts which et
to of Ocupa requirerrcmswhich must be met
prior to Isility to unce of a Certificate
prior to Issuance ofaCertificate of Occupancy.
i/s rW
'�� Q7 Cupe s}y6tl
_
ISSUED BYA '11hk ✓tz-`
Owner or authorized agent Date
TOTAL:
OFFICE COPY
J